In Reply.—Dr Dedo touches on the evils
of utilization review, of lawyers, and of medical directors of managed care
companies. The purpose of my Commentary was not to debate the merits of the
legal system, the qualifications of medical directors of managed care organizations,
or the efficiency and effectiveness of utilization review in improving quality
of care. Rather, my purpose was to suggest that the reason we have witnessed
these fundamental changes in the way we practice medicine is that the fee-for-service
system was not perceived to be producing sufficient value for the money invested
in it. Literally hundreds of studies have documented that there were wide
and unacceptable variations in the level of quality care and that the mean
level of quality of care provided to the American people was not what was
desired by them or by their physicians.